Event Notification Report for April 19, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/18/2021 - 04/19/2021
Agreement State
Event Number: 55199
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: Loyola University Medical Center
Region: 3
City: Maywood State: IL
County:
License #: IL-01131-02
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Jeffrey Whited
Licensee: Loyola University Medical Center
Region: 3
City: Maywood State: IL
County:
License #: IL-01131-02
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Jeffrey Whited
Notification Date: 04/19/2021
Notification Time: 17:53 [ET]
Event Date: 04/19/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/19/2021
Notification Time: 17:53 [ET]
Event Date: 04/19/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/19/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PETERSON, HIRONORI (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PETERSON, HIRONORI (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 5/19/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"[The licensee] contacted the Agency this afternoon to report a medical underdose of Y-90 that occurred today, April 19, 2021. Although information provided was preliminary, no untoward medical impact is expected to the patient.
"[The] Radiation Safety Officer for the licensee contacted the Agency at 1515 CDT on April 19, 2021, to report a patient scheduled to receive Y-90 microsphere therapy (Theraspheres) for hepatocellular cancer received only 63 percent of the dose prescribed in the written directive. The Agency understands this to be one of three fractions delivered. Additional data is forthcoming.
"Reportedly, the underdosing was due to a leakage of Y-90 microspheres in the connection between the Therasphere tubing and the microcatheter. The leakage resulted in area and personnel contamination which was promptly and successfully addressed by on-site radiation safety staff. No skin doses are reported or anticipated.
"[The Agency] will dispatch staff to the site tomorrow for a reactionary inspection."
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"[The licensee] contacted the Agency this afternoon to report a medical underdose of Y-90 that occurred today, April 19, 2021. Although information provided was preliminary, no untoward medical impact is expected to the patient.
"[The] Radiation Safety Officer for the licensee contacted the Agency at 1515 CDT on April 19, 2021, to report a patient scheduled to receive Y-90 microsphere therapy (Theraspheres) for hepatocellular cancer received only 63 percent of the dose prescribed in the written directive. The Agency understands this to be one of three fractions delivered. Additional data is forthcoming.
"Reportedly, the underdosing was due to a leakage of Y-90 microspheres in the connection between the Therasphere tubing and the microcatheter. The leakage resulted in area and personnel contamination which was promptly and successfully addressed by on-site radiation safety staff. No skin doses are reported or anticipated.
"[The Agency] will dispatch staff to the site tomorrow for a reactionary inspection."
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
Power Reactor
Event Number: 55200
Facility: Browns Ferry
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: Wesley Conkle
HQ OPS Officer: Donald Norwood
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: Wesley Conkle
HQ OPS Officer: Donald Norwood
Notification Date: 04/20/2021
Notification Time: 15:36 [ET]
Event Date: 04/19/2021
Event Time: 18:10 [CDT]
Last Update Date: 04/20/2021
Notification Time: 15:36 [ET]
Event Date: 04/19/2021
Event Time: 18:10 [CDT]
Last Update Date: 04/20/2021
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
MILLER, MARK (R2)
FFD GROUP, (EMAIL)
MILLER, MARK (R2)
FFD GROUP, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | N | 0 | Hot Shutdown | 0 | Hot Shutdown |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 5/20/2021
EN Revision Text: FITNESS-FOR-DUTY REPORT - EMPLOYEE SUPERVISOR CONFIRMED POSITIVE FOR ALCOHOL
A non-licensed, employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The licensee notified the NRC Resident Inspector.
EN Revision Text: FITNESS-FOR-DUTY REPORT - EMPLOYEE SUPERVISOR CONFIRMED POSITIVE FOR ALCOHOL
A non-licensed, employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The licensee notified the NRC Resident Inspector.